Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
As a continuation of our blog series, here are details around the clarification of requirements for administering the Advance Beneficiary Notice of Non-Coverage(SNFABN).
- ABN Advance Beneficiary Notice of Non-Coverage (SNFABN CMS 10055) or SNF Denial Letters are known as the traditional denial letters, or SNF Advance Beneficiary Notice (SNF ABN).
Medicare Part A SNFABN (Form CMS-10055)
SNF ABN denying coverage and the resident has days available in their Medicare Part A and they are staying in the facility (regardless of secondary payor source).
- The Advanced Beneficiary Notice is issued to Medicare Part A beneficiaries when they are being discontinued from their skilled benefit and they will remain in the facility when the facility determines that they do not meet the qualifications for skilled care.
These letters are only given in situations where the resident remains in the facility receiving non-covered care at the conclusion of Medicare Part A coverage.
- The SNF provider uses the SNF ABN (CMS 10055) to notify the beneficiary of their liability for continued services. The purpose of this notice is to provide the beneficiary with the opportunity in writing to request that the SNF submit a demand bill to the fiscal intermediary or Medicare Administrative Contractor (MAC) before receiving physician-ordered services that are non-covered due to a lack of medical necessity or because the services are custodial care. The demand bill process is separate and distinct from the QIO review process and does not apply to Medicare Advantage Plan enrollees.
- Residents or their legal representative must sign notices to verify receipt; however, if the resident is unable to receive the notice and the resident’s legal representative is unavailable, the SNF provider may contact the legal representative and inform him/her by phone. The SNF provider must immediately follow up the phone notification with a written notice. The date of the telephone contact is the date the notice was given as long as it is not disputed by the beneficiary.
- If the patient is being discharged home on the date that the team, including the patient, has determined is appropriate for the patient, the ABN is not required to be given.
- Routinely issuing the ABN to all patients that are returning home in case they remain in the facility is not required. The team should maintain open communication with patients planning to return home and team members to verify the delivery of the SNFABN to patients who do remain in the facility after discontinuance of their skilled benefit even if only for a few days after their originally planned discharge date.
Medicare Part B SNFABN (Form CMS-R-131)
SNFs will continue to use the ABN, Form CMS-R-131 for items or services that may be denied by Medicare paid under Medicare Part B to inform beneficiaries of their potential liability.
- Not reasonable and necessary (“medical necessity”) for the diagnosis or treatment of illness, injury, or to improve the functioning of a malformed body member (§1862(a)(1) of the Act); or
- Custodial care (“not a covered level of care”) (§1862(a)(9) of the Act).
- Prior to delivery of the care item or service in question. Provide enough time for the beneficiary to make an informed decision on whether or not to receive the service or item in question and accept potential financial liability.
Our next blog post will finish the five part series on NONMC and ABN.
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